Video: Controversy over breast cancer screening

Closed captioning of: Controversy over breast cancer screening

>>>hello, everyone. welcome. i'm dr.
nancy snyderman
.
breast cancer
, the number two killer of
women
in america and has been drill under to our heads to get screened early, that is until today. new guidelines advising
women
ages 40 to 49 not to get routine mammography unless they are at risk for
breast cancer
. instead, screening recommendations now to start at the age of 50 and then every two years until the age of 74. with
women
, ages 60 to 69, those at the highest risk group because of their age, they're most likely to see the biggest benefit. but these are changes that are meeting a fierce debate.
susan
, let me start with you. big headlines all over the country today about changing recommendations for screening mammography. are these recommendations on target or off target?

>>i think they're on target. they really bring us into line with the
rest of the world
. they bring nus to line with the scientific data. we have been doing mammography in younger
women
really based on wishful thinking and hoping that it is going to work and the evidence is that the risks are higher than the benefits in the younger
women
. i think it's about time that we actually change the guidelines to reflect that.

>>len, the
american cancer society
has been adamant that you're going to stick with the screening for the 40-year-old
age group
. you along with
american college of radiology
and a couple groups that are sticking with the new idea, that is the
national breast cancer coalition
, the
national cancer institute
said they're going to reevaluate their suggestions,
breast cancer action
, national
women
's health network. why are you hesitant to embrace these new recommendations?

>>well, nancy, i don't know that i would say we're hesitant. by the way, many groups, many well-reflected professional groups that agree we should not change our approach and certainly a topic of discussion among scientists and experts for some time to come. no doubt about that. we have looked that evidence and looked that same evidence as the
task force
and we have come to the conclusion that the
science
does back up screening beginning at the age of 40 and, in particularly, that 40 to 49
age group
. the reality is that
breast cancer
deaths, since
1990
, according to that same study have declined over 3% per year since
1990
in
women
aged 40 to 49. we don't think the evidence is sufficient to change our recommendation at this time based on the success we had in screening
women
to this point.

>>susan
?

>>but, actually, a lot of that decrease of deaths is not from mammography screening, but from chemotherapy and better treatments and you can't claim that for mammography. if you look at the randomized studies, you have to follow
women
for 10 to 12 years to see any benefit and by then they're in their 50s. the problem is, these mammograms in
young women
are not freebies. there's an increase in
false negatives
and an increase in
false negatives
and radiation risk of the mammography cuative cumatively and it's a wash. the benefits really don't outweigh the risks when you look at it as a public policy issue. and i think for us to be continuing to recommend something, instead of finding something that really works better, is really not, not right.

>>len, i think one thing that has come up repeatedly this morning we seem to have anecdotes and new
science
. any time we have a seismic shift in the message, i have been one of the people telling people to get screened early. i'm part of that big message until now but any time we have a seismic shift, hard to accept a new reality. is that the trouble here or do you really think the data is that flawed?

>>let's be clear here. all of us want to do the right thing for
women
and all of us want to look at the signs. experts can look at the same signs and come to the same conclusion. the same
science
is a
computer model
and the reality is when you look at the data coming out of that model, coming into the model and out of that model, serious concerns whether you can take a
computer model
to tell us how to treat millions of
women
. and we're not comfortable --

>>oh, come on.

>>no, i'm very serious about that. i want you to share with me.

>>no, but the data, but the data that the
computer model
. what they've done, they've taken datas from large
randomized controlled trials
that have been lots in good studies that we all agree upon and they're just using that to try different scenarios to see where the risk benefit actually pans out. so --

>>not so simple, though.

>>the
computer model
is the exact right way to do that.

>>not so simple. each one of those models is designed differently and different inputs and each model has different outputs and took all that data and let me share one additional thought.

>>that's the strength of it. they all came out with the same conclusion.

>>they did not come out with the same conclusion and same data. let me share something else with you. very bright people have done
computer models
particularly in the financial world. they thought they could predict reality and look at the mess that we're in because of that. when you accept this
computer model
, let me finish here, when you accept that
computer model
as being accurate, i would suggest before you bring it out that you take the time to subject it to scientific scrutiny and now you're going to say we're going to treat millions of
women
based on a
computer model
and have not had a chance to critique and the reality plenty of data on
real women
there that shows it doesn't work. that shows it doesn't work. that's the issue. not like --

>>we do think.

>>it's not like the
computer model
is telling us something different than what the studies have shown. all the studies have shown it doesn't make a difference in younger
women
and it -- well --

>>i disagree.

>>in this country when we had a consensus conference in
1997
saying should we treat
women
under 50 the answer was no. and then how did we start treating
women
under 50 because the senate passed a nonbinding resolution told the nci that they should change their recommendations, not based on
science
, based on, you know, yelling and screaming by the radiologist and by other groups.

>>i agree. we should not be treating
women
by politics. you're absolutely right on that.

>>not doing it. we didn't start this based on
science
and, you know, it's about time we recognize that and we stopped doing it.

>>that's not true.
science
, the
science
suggested a long time ago, the start of age 40 is right.

>>no, no, that's not true. and we're one of the few countries that do this.

>>that doesn't mean the other countries are necessarily right, does it?

>>well --

>>they have the same results we do.

>>on that note, politics and
breast cancer
, politics in washington, d.c., and i want to thank both of you. dr.
susan
love and lin, thank you. a controversy that is going to stay with us for the next couple day as we hash out what these numbers really mean. my thanks to both of you.

NEW YORK — For many women, getting a mammogram is already one of life's more stressful experiences.

Now, women in their 40s have the added anxiety of trying to figure out if they should even be getting one at all.

A government task force said Monday that most women don't need mammograms in their 40s and should get one every two years starting at 50 — a stunning reversal and a break with the American Cancer Society's long-standing position. What's more, the panel said breast self-exams do no good, and women shouldn't be taught to do them.

The news seemed destined to leave many deeply confused about whose advice to follow.

"I've never had a scare, but isn't it better to be safe than sorry?" asked Beth Rosenthal, 41, sitting in a San Francisco cafe on Monday afternoon with her friend and their small children. "I've heard of a lot of women in their 40s, and even 30s, who've gotten breast cancer. It just doesn't seem right to wait until 50."

For most of the past two decades, the American Cancer Society has been recommending annual mammograms beginning at 40, and it reiterated that position on Monday. "This is one screening test I recommend unequivocally, and would recommend to any woman 40 and over," the society's chief medical officer, Dr. Otis Brawley, said in a statement.

But the government panel of doctors and scientists concluded that getting screened for breast cancer so early and so often is harmful, causing too many false alarms and unneeded biopsies without substantially improving women's odds of surviving the disease.

"The benefits are less and the harms are greater when screening starts in the 40s," said Dr. Diana Petitti, vice chair of the panel.

The new guidelines were issued by the U.S. Preventive Services Task Force, whose stance influences coverage of screening tests by Medicare and many insurance companies. But Susan Pisano, a spokeswoman for America's Health Insurance Plans, an industry group, said insurance coverage isn't likely to change because of the new guidelines.
Video: Breast cancer test at 50, not 40, study says

Experts expect the revisions to be hotly debated, and to cause confusion for women and their doctors.

"Our concern is that as a result of that confusion, women may elect not to get screened at all. And that, to me, would be a serious problem," said Dr. Len Lichtenfeld, the cancer society's deputy chief medical officer.

The guidelines are for the general population, not those at high risk of breast cancer because of family history or gene mutations that would justify having mammograms sooner or more often.

The new advice says:

Most women in their 40s should not routinely get mammograms.

Women 50 to 74 should get a mammogram every other year until they turn 75, after which the risks and benefits are unknown. (The task force's previous guidelines had no upper limit and called for exams every year or two.)

The value of breast exams by doctors is unknown. And breast self-exams are of no value.

Video: Dr. Nancy answers viewers' mammogram questions
Medical groups such as the cancer society have been backing off promoting breast self-exams in recent years because of scant evidence of their effectiveness. Decades ago, the practice was so heavily promoted that organizations distributed cards that could be hung in the shower demonstrating the circular motion women should use to feel for lumps in their breasts.

The guidelines and research supporting them were released Monday and are being published in Tuesday's issue of the Annals of Internal Medicine.

Sharp criticism from cancer societyThe new advice was sharply challenged by the cancer society.

"This is one screening test I recommend unequivocally, and would recommend to any woman 40 and over," the society's chief medical officer, Dr. Otis Brawley, said in a statement.

The task force advice is based on its conclusion that screening 1,300 women in their 50s to save one life is worth it, but that screening 1,900 women in their 40s to save a life is not, Brawley wrote.

That stance "is essentially telling women that mammography at age 40 to 49 saves lives, just not enough of them," he said. The cancer society feels the benefits outweigh the harms for women in both groups.

International guidelines also call for screening to start at age 50; the World Health Organization recommends the test every two years, Britain says every three years.

Breast cancer is the most common cancer and the second leading cause of cancer deaths in American women. More than 192,000 new cases and 40,000 deaths from the disease are expected in the U.S. this year.

Rates of women who are opting for preventive mastectomies, such as Angeline Jolie, have increased by an estimated 50 percent in recent years, experts say. But many doctors are puzzled because the operation doesn't carry a 100 percent guarantee, it's major surgery -- and women have other options, from a once-a-day pill to careful monitoring.

Mammograms can find cancer early, and two-thirds of women over 40 report having had the test in the previous two years. But how much they cut the risk of dying of the disease, and at what cost in terms of unneeded biopsies, expense and worry, have been debated.
Video: Many docs disregarding new mammogram guidelines

In most women, tumors are slow-growing, and that likelihood increases with age. So there is little risk by extending the time between mammograms, some researchers say. Even for the minority of women with aggressive, fast-growing tumors, annual screening will make little difference in survival odds.

The new guidelines balance these risks and benefits, scientists say.

The probability of dying of breast cancer after age 40 is 3 percent, they calculate. Getting a mammogram every other year from ages 50 to 69 lowers that risk by about 16 percent.

"It's an average of five lives saved per thousand women screened," said Georgetown University researcher Dr. Jeanne Mandelblatt.

False alarmsStarting at age 40 would prevent one additional death but also lead to 470 false alarms for every 1,000 women screened. Continuing mammograms through age 79 prevents three additional deaths but raises the number of women treated for breast cancers that would not threaten their lives.

"You save more lives because breast cancer is more common, but you diagnose tumors in women who were destined to die of something else. The overdiagnosis increases in older women," Mandelblatt said.

Are you at risk for breast cancer? She led six teams around the world who used federal data on cancer and mammography to develop mathematical models of what would happen if women were screened at different ages and time intervals. Their conclusions helped shape the new guidelines.

Several medical groups say they are sticking to their guidelines that call for routine screening starting at 40.

"Screening isn't perfect. But it's the best thing we have. And it works," said Dr. Carol Lee, a spokeswoman for the American College of Radiology. She suggested that cutting health care costs may have played a role in the decision, but Petitti said the task force does not consider cost or insurance in its review.

The American College of Obstetricians and Gynecologists also has qualms. The organization's Dr. Hal Lawrence said there is still significant benefit to women in their 40s, adding: "We think that women deserve that benefit."

But Dr. Amy Abernethy of the Duke Comprehensive Cancer Center agreed with the task force's changes.

"Overall, I think it really took courage for them to do this," she said. "It does ask us as doctors to change what we do and how we communicate with patients. That's no small undertaking."

Abernethy, who is 41, said she got her first mammogram the day after her 40th birthday, even though she wasn't convinced it was needed. Now she doesn't plan to have another mammogram until she is 50.

Barbara Brenner, executive director of the San Francisco-based Breast Cancer Action, said the group was "thrilled" with the revisions. The advocacy group doesn't support screening before menopause, and will be changing its suggested interval from yearly to every two years, she said.

Mammograms, like all medical interventions, have risks and benefits, she said.

"Women are entitled to know what they are and to make their best decisions," she said. "These guidelines will help that conversation."

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